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Illinois Entrepreneurship Network
Request for Counseling Illinois Small Business Development Center
Funded in part through a cooperative agreement with SBA
1. Type of Contact:
Face to Face
Online
Telephone
2. Name of Primary Counselor: 5. Client Email: 9. Client Fax Number: 6. Position:
Business Owner
PART I: Client Intake:
3. Date Company Established: 4. Client Name (last, First, MI): 8. Client Home Phone:
___ /___/___
7. Client Work Phone: 11. Client Home Address: 14. Client Zip Code: 15. Zip +4: 16. Client County:
10. Client Cell Number: 13. Client State:
12. Client City:
17. Client Federal Representative District Number: 20. Client Gender:
Male Female
18. Client State Representative District Number: 21. Client Race:
Asian Black or African American Native American or Alaskan Native Native Hawaiian or other Pacific Islander White
19. Client State Senate District Number: 23.Client Veteran Status:
Non-Veteran Service-Disabled Veteran Veteran
22. Client Ethnicity:
Hispanic Origin Not of Hispanic Origin
24. Client Reservist Status:
National Guard None National Guard-Active Duty Reservist Reservist-Active Duty
25. Disabled:
No Yes
PART II: Company Intake:
26. Company Name: 29. Company Phone #: 34. Total No. of Employees:
(Full & Part Time)
27. Company Email: 30. Company Fax #: 35. Business Size: 31. Company FEIN:
28. Company Website: 33. Company DUNS #:
32. Company Cage Code:
Large Other Small 36. Annual Sales: 2004 2005 2006 Disadvantaged Small Certified SDB or SBA 8(a) 2007 Projected 2008 Minority-Owned Small Woman-Owned Small 37. Type of Business:(choose primary category) Surplus Dealer Professional, Scientific & Technical Services Mining Manufacturer/Producer Real Estate & Rental & Leasing Management of Companies & Enterprises Utilities Finance & Insurance Health Care & Social Assistance Agriculture, Forestry, Fishing & Hunting Information Wholesale Dealer Accommodation & Food Services Administrative & Support Construction Public Administration Arts, Entertainment & Recreation Waste Management & Remediation Services Retail Dealer Educational Services Transportation & Warehousing Other Services (except Public Administration)
R&D
38. Miscellaneous:
International Trade Home-based Business Online Business
39. What is the legal entity of your business:
Sole Proprietorship Corporation LLC S-Corporation Partnership Other (specify) ________________________________
40. Company Gender:
Male >50% Female > 50% Male/Female 50/50
41.Company Veteran Status:
Non-Veteran Service-Disabled Veteran Veteran
42. Company Address:
43. Company City:
44. Company State:
45. Company Zip Code:
46. Company County:
47. Company Federal Representative District Number: 50. Is Business in a HUBZone:
No Located in HUBZone Only Certified HUBZone? Date Certified __________
48. Company State Representative District Number: 51. Is Business Located in Distressed Area:
No Yes
49. Company State Senate District Number: 52. Keywords
53. Product Service Codes (PSCs): 56. Product or service description:
54. Standard Industrial Classification SICs:
55. North American Industrial Classification (NAICs):
57. Signature Date:
58. SBA Client Type:
Applicant Surety Bond
___ /___/___
8(a) & Borrower Borrower None
8(a) & Surety Bond COC Technical Assistance
8(a) Client Procurement Assistance
59. State of Incorporation
60 Referral From: Please Specify: 61. Specific assistance requested:
ANY CHANGES TO THIS FORM OR THE USE OF ANY OTHER INTAKE FORMS MUST HAVE PRIOR WRITTEN APPROVAL OF THE SMALL BUSINESS DEVELOPMENT CENTER STATE DIRECTOR Updated 4/27/2006
CLIENT RIGHTS AND RESPONSIBILITIES
Funded in part through a cooperative agreement with SBA
As a new client of the Illinois Small Business Development Center (SBDC), we'd like to advise you of certain rights and responsibilities you have as one of our clients:
You have a right to expect: • prompt, courteous, and professional counseling services and to be advised if the Illinois SBDC is unable to provide service within the time frame required. Be aware that due to the demand for our services, cases must often be prioritized by need and training may be recommended before counseling is provided. • all information shared with the Illinois SBDC and any of its resources (staff, faculty, volunteers, and consultants) will be held in strictest confidence. No information provided by you will be used to the commercial advantage of any staff member, consultant, or other resource of the Illinois SBDC or to the benefit of any third party. • that your client status with the Illinois SBDC will remain confidential. No public use of your name, address, or business identity will be made without your prior approval. Please note, however, that the Illinois SBDC is funded in part by the U.S. Small Business Administration, Department of Commerce and Economic Opportunity and the local host so, limited information with respect to your client status is provided to those entities. Our role is to counsel and assist small business owners and those planning to go into business. We will not make business decisions or judgments for you, though we will make recommendations and suggestions as appropriate. These will be based upon our best efforts to apply the experience and resources available to us to assist you in making your own business decisions. The Illinois SBDC may charge reasonable fees for training programs, special services, and publications. However, you have a right to feel secure that no fee will be charged by the ISBDC or its resources for normal counseling services provided to you. Also, no recommendations will be made as to the purchase of goods or services from any individual or firm with whom any ISBDC staff or its resources have any financial, familial or personal interest. The counseling services provided to you are a part of the effort of the Illinois SBDC and its sponsors to respond to the growing needs of the small business community and to positively affect the economy of Illinois. They are not intended to compete with, replace, or be a substitute for services available from the private sector. Clients whose needs can be fully met by private sector practitioners or firms in an affordable manner will be encouraged to use those resources. In consideration of the Illinois SBDC furnishing you with management and technical assistance, you agree to waive all claims against the ISBDC and its constituent institutions, its staff, or any other resources employed by or used in connection with these services. You will also be expected to cooperate with the ISBDC in its efforts to assure the quality and effectiveness of the counseling services it provides. In this respect, the Illinois SBDC will ask all clients who receive counseling assistance to complete a written evaluation of the services provided. In addition, all clients will be asked to complete a Economic Impact Verification form that documents the assistance provided by the Illinois SBDC. Finally, clients may receive direct inquires from this office, the State Director's office or the U.S. Small Business Administration with respect to the services provided to you. Your response to all of these inquiries will be greatly appreciated.
REQUEST FOR COUNSELING
SBDC Agreement: “I request business management counseling from the Illinois Small Business Development Center a U.S. Small Business Administration resource partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate SBDC and SBA assistance services. I understand that any information received by an Illinois SBDC counselor will be held in strict confidence by the counselor to the extent allowable by law. I further understand that the Illinois SBDC counselor has agreed not to: (1) recommend goods or services from sources in which the individual counselor has an interest; and (2) accept fees or commissions developing from the counseling relationship. In consideration of the provision of management and/or technical assistance by a resource partner counselor, I agree to waive all claims arising out of this assistance, against SBA personnel, the resource partner from whom I sought assistance, its host organizations, and the counselor(s) arising from this assistance.”
________________________________________________ Client Signature
__________________________________ Date
_______________________________________________ Counselor Signature
We welcome you as a client and encourage you to call on us if you have any questions or comments with regard to your rights and responsibilities or services you receive. You can do so by calling your local Illinois SBDC counselor or the Illinois SBDC State Office at (800) 252-2923.
ANY CHANGES TO THIS FORM OR THE USE OF ANY OTHER INTAKE FORMS MUST HAVE PRIOR WRITTEN APPROVAL OF THE SMALL BUSINESS DEVELOPMENT CENTER STATE DIRECTOR Updated 4/27/2006
REQUEST FOR COUNSELING FORM (RFC)
INSTRUCTIONS
Below is a brief explanation of some of the fields you will need to complete on the RFC Form. You can type your responses
on the PDF, but you will need to print the document in order to sign the second page. The field boxes shaded in gray DO NOT need to be filled out if you do not know the information. Once again, please be sure to sign the second page on the client signature line. Please email or fax your form to sbdc@uic.edu or (312) 355-3604. DEFINITION OF TERMS: Client: The client is the individual. There is a separate section for company information. Client Home Address: Use the personal address (P.O. Box alone can not be accepted.) Company Address: Use the physical street address where company is located. In-Business: Completed required registration (s) , if applicable, with the local, state, and/or Federal government (e.g. DBA registration, business license, tax identification number, etc.) and at least one of the following: a) as documented a transaction from the sale of a product or service for the purpose of gain or profit; b) has contracted for or compensated an employee (s) or independent contractor (s) to perform the essential business functions; c) has acquired debt or equity capital to pursue business operations (e.g. to purchase inventory, equipment, building, business, etc.); d) has incurred business expenses in the operation of a business. Nascent (Pre-venture) Entrepreneur: An individual who has taken one or more active steps to form a business. This includes seeking assistance from SBA and/or one of its resource partners. INSTRUCTIONS FOR PRE-VENTURES (Individuals who have not started a business yet)
Page 1 PART I: Client Intake #4 - #16 Please write your name and personal contact information in these fields. #11 CLIENT HOME ADDRESS: Unfortunately, our governmental database does not accept PO Boxes as a mailing address, so please use your home address
PART II: Company Intake:
#26 COMPANY NAME: Since you have not started the business yet, you do not have to fill out the fields #26 through #55. #56 PRODUCT OR SERVICE DESCRIPTION… Please indicate the product or service your company will offer. #61 SPECIFIC ASSISTANCE REQUESTED: Please indicate the type of assistance you are seeking from our center. Once again, the gray boxes are fields you DO NOT have to be completed if you do not know the answers (e.g. #s 17, 18, 19, 32, 33, 47, 48, 49, 50, 51, 52, 53, 54, 55, & 58). Page 2 Read, sign and date it.
INSTRUCTIONS FOR EXISTING BUSINESSES
Page 1
Part I: Client Intake
#3 Date company was established #4 through #16 Please write your name and personal contact information in these fields. Do not write the contact information for the business in these fields because that will be requested in fields #26 through #30 and #42 through #46.
PART II: Company Intake:
#26 COMPANY NAME: Please write the legal name of the business. If you do not recall the legal name, then simply use the name that you use on your business cards and marketing materials. #27 through 31 Please fill out all fields. Write “none” as appropriate (i.e. if the business doesn’t have a website, fax, etc.) #38 If the company is a home-based or online business or if it is involved in international trade, check all the applicable boxes #56 PRODUCT OR SERVICE DESCRIPTION: Please indicate the product or service your company offers #61 SPECIFIC ASSISTANCE REQUESTED: Please indicate the type of assistance you are seeking from our center. Page 2 Read, sign and date it.
Please fax or email the completed form to (312) 355-3604 or sbdc@uic.edu